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InfraGard Membership Application
Please complete and submit the following form to apply for InfraGard membership. All fields are required unless otherwise noted.
Applicant Information
Name and Employer
First: Middle Initial: Last:
Maiden Name: (if applicable)
Employer: Title:
Business Address
Physical Address Required. No PO Boxes.
Home Address
Physical Address Required. No PO Boxes.
Street: Street:
City: City:
State: Zip Code: State: Zip Code:
Chapter Selection
Chapter: Find your local chapter name here.
Contact Information
Business Email:
Alternate Email:
(optional)
Work Phone: Home: (optional) Cell: (optional)
ex: 123-456-7890 (10 digits, hyphen separation only)
Fax:
(optional)
Other Information
Birth Date:
ex: 01/01/1955
City of Birth:
County: State: Country:
Applicant is a Domestic InfraGard Applicant if he/she is a US Citizen by birth as defined by 8 USC 1401-1409, or US Citizen by Naturalization as defined by 8 USC 1421-1459, or Lawful Permanent Resident as defined by 8 CFR ' 245.
U.S. Citizen: Yes No
Alien Registration Number: Only, if you are not a U.S. Citizen.
Alphanumeric characters only, exclude hyphens or separators.
Social Security
Number:
ex: 123456789 (9 digits, exclude hyphens or separators)
Drivers License
Number: State Issued:
Alphanumeric characters only, exclude hyphens or separators.
Enter "None" if you do not have a U.S. drivers license.
Code Word:
A code word is used for authentication when contacting Help Desk.
Examples include mother's maiden name, city of birth, etc.
Additional Questions
1. Have you ever been arrested for, charged with, OR convicted of a felony or misdemeanor, even if expunged from your record? If yes, please enter a short explanation of the occurrence(s) making sure to include dates, agencies involved, case numbers (if known), disposition, and any additional information that you feel would assist us in making a membership decision. Include Driving Under Influence (DUI) offenses but exclude speeding and parking tickets.
Yes
No
Description: (limited to 1024 characters)
2. Have you ever had your employment terminated, suspended, OR otherwise end, based on - or within one year of - an accusation that you committed fraud, theft, misappropriation, commingling of funds, breach of trust, breach of contract, or a similar violation involving honesty? If yes, regardless of whether a mutual resolution ultimately was reached, please explain the occurrence(s) making sure to include dates, agencies involved, case numbers, disposition, and any additional information that you feel would assist us in making a membership decision.
Yes
No
Description: (limited to 1024 characters)
3. Have you ever been censured, suspended, disbarred from, OR otherwise had your membership terminated by a professional organization/association for reasons other than the failure to pay dues? If yes, regardless of whether a mutual resolution ultimately was reached, please explain the occurrence(s) making sure to include dates, agencies involved, case numbers, disposition, and any additional information that you feel would assist us in making a membership decision.
Yes
No
Description: (limited to 1024 characters)
4. May we share your contact information with other InfraGard members?
Yes
No
5. Have you applied to InfraGard before, or were you previously a member?
Yes
No
Agreement
Membership Responsibilities and Privacy Act Statement
Membership Responsibilites
If accepted as a member of InfraGard, Applicant may receive information that is sensitive and not publicly available ("Protected Information"). Protected Information may be provided by or through the InfraGard National Organization, InfraGard chapters, InfraGard members, partners of InfraGard, or other sources, and will be marked accordingly. If accepted as an InfraGard member, Applicant understands and agrees to the following terms regarding Protected Information.
1. Participation is Voluntary. Applicant is not obligated as a condition of InfraGard membership to disclose any information to the InfraGard National Organization or any InfraGard chapter, partner, or member.
2. Confidentiality and Non-Disclosure. Protected Information is to be regarded as Business Confidential and shall not be disclosed beyond its intended scope.
3. No Guarantee of Fitness. Protected Information is provided as a service to InfraGard members and may be unevaluated and unverified. As such, Protected Information is not guaranteed to be accurate, complete, or actionable.
4. Submission in Good Faith. Applicant agrees that he/she will not submit information which he/she knew at the time of submission to be false, and that he/she will submit information only to further InfraGard's stated purposes.
5. Federal Agencies Will Exercise Care to Protect Information. To the extent allowed by law, information received from InfraGard members that is marked "InfraGard Protected Information" shall be protected from agency disclosure under 5 USC 552 (commonly referred to as the Freedom of Information Act ("FOIA")), and from publication, divulgence, or release in any other manner pursuant to the prohibitions of the Trade Secrets Act, 18 USC 1905.
6. Membership Profiles. Applicant agrees to participate in membership surveys as necessary to assist the FBI in gauging the knowledge and expertise of the InfraGard membership. (The profile is approximately 20 questions and may take 5-10 minutes to complete.)
Applicant understands and agrees that InfraGard is not to be commercially exploited as a forum to market products or services and that doing so may result in the revocation of Applicant's membership in InfraGard.
Applicant, if accepted as an InfraGard member, agrees to act in a manner consistent with the InfraGard National Bylaws, as the Bylaws may be amended from time to time, as well as any other duly enacted national requirements of InfraGard.
Applicant requirements:
* At least 18 years of age on the date of completion of this Application.
* Consent to a records check that yields a satisfactory result as determined by the FBI in its sole discretion.
* Consent to periodic re-confirmation of membership requirements.
* Agree to and complete this InfraGard Membership Application Form.
* Any further requirements (if more restrictive) mandated by the local chapter and approved by the FBI.
Privacy Act Statement
Authority:
Collection of this information is authorized under: Title 28, Section 534 28 CFR. 0.85.
Principal Purpose and Routine Uses
The information collected on this form will be used for the principal purpose of conducting security risk assessments on InfraGard Members and applicants. As part of this assessment, the collected data may also be used to assist in determining approval, denial, revocation or renewal of access to the InfraGard Secure web site and the authorization to receive InfraGard sensitive information. Information provided by me will be protected and used in strict compliance with the Privacy Act and the routine uses most recently published in the Federal Register for the FBI's Central Records System (Justice/FBI-002) and the FBI's Blanket Routine Uses (Justice/FBI-BRU).
Social Security Account Number
Your Social Security Account Number (SSAN) is requested to check criminal, immigration, national security and other electronic databases. Because other people may have the same name and birth date, your SSAN will be used to facilitate accurate identification and to help eliminate the possibility of misidentification of individuals for whom a security risk assessment or database check is being conducted.
Effects of Nondisclosure or Falsification
Completion of this application and provision of your SSAN is voluntary. However, failure to provide the requested information may result in your application being rejected for membership in InfraGard or your membership revoked. Knowingly falsifying or concealing information requested on this form will result in your application being rejected or your membership revoked. In addition, Title 18 Section 1001 of the U.S. Code provides that knowingly falsifying or concealing a material fact may under certain circumstances constitute a felony resulting in fines and/or imprisonment.
Consent
By completing an InfraGard Membership Application Form, I hereby authorize the FBI to obtain and verify any information relevant to assessing my suitability to access, possess, use, receive or transfer sensitive InfraGard Information. This information may include, but is not limited to, law enforcement and intelligence information. I further authorize the FBI to disclose information obtained in connection with my security risk assessment in order to verify the accuracy of completeness of the information I have provided to the FBI
I understand that this is a legally binding document and false statements provided by me are violations of federal law and may lead to criminal prosecution or other legal action. To the best of my knowledge and belief, I affirm that a). I meet all of the requirements to be an InfraGard member; b). The information I have provided herein is true, complete and correct; and c). I have reviewed the InfraGard Code of Ethics and I agree to abide by its covenants.
I have read, understand, and agree with the above consent information
Verification
Please enter the verification code from the image into the field below.
Verification Code:
